Thyroid status examination

Thyroid status examination and questions for medical student exams, finals, OSCEs and MRCP PACES

Intro (WIIPPPPEE)

• Wash your hands
• Introduce yourself
• Identity of patient – confirm
• Permission (consent and explain examination)
• Pain?
• Position sitting in chair with room behind the chair for the examiner to stand
• Privacy
• Expose neck and clavicles (patient may need to tie hair back/ remove necklace)

General Inspection

• Surroundings
  • Monitoring, walking aids
• Patient

• Well or unwell?
• Hyperthyroid
  • Heat intolerant, flushed, sweaty, fidgety, thin
• Hypothyroid
  • Cold intolerant, lethargic, hoarse voice, overweight

Systemic examination

• Hands
  • Inspect
    • Palmar erythema (hyperthyroid)
    • Thyroid acropachy
      • Clubbing and digit swelling in Graves’ disease
  • Palpate
    • Temperature
      • Hot and clammy if hyperthyroid
      • Cold if hypothyroid
    • Pulse
      • Tachycardia or atrial fibrillation (hyperthyroid)
    • Tremor
      • Best seen by resting a piece of paper on patient’s outstretched hands
      • Fine tremor (hyperthyroid)
• Face
  • Hypothyroid:
    • Coarse facies
    • Thin hair.
      • Loss of the lateral third of the eyebrows (Hertoghe’s sign) is highly variable
• Eyes
  • Inspection
    • Chemosis (conjunctival oedema)
    • Exopthalmos (Graves’ Disease)
      • Warn the patient you will go behind them. From behind, look down to see if the patient’s eyes protrude
    • Test eye movements
      • Complex ophthalmoplegia (diplopia not consistent with one cranial nerve palsy)
      • Lid retraction
        • Upper lid is retracted upwards and lower lid is retracted downwards
      • Lid lag
        • Sclera can be seen between iris and upper eyelid when patient looks down due to delay in eyelid movement
    • Relative afferent pupillary defect (RAPD – hyperthyroid)
•  Trunk
  • Proximal myopathy (hyper/hypothyroid)
    • Ask patient to cross arms and stand up from chair
•  Legs
  • Pretibial myxoedema (Graves’ Disease)
  •  Reflexes
    • Brisk (hyperthyroid)
    • Slow-relaxing (hypothyroid)

Closure

• Thank patient
• Patient comfortable?
• Help getting dressed?
• Wash hands
• Turn to examiner, hands behind back, holding stethoscope (try not to fidget!) before saying: “To complete my examination, I would like to…”
  • Take a full history
  • ECG
  • Urine dipstick
•  Ask to look for associated features:
  • T2DM
  • Addisons disease
  • Pernicious anaemia
  • Vitiligo
  • Rheumatoid arthritis
  • SLE

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Common Thyroid status examination exam questions for medical students, finals, OSCEs and MRCP PACES

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